19865APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:19865
PERMIT NO.
^ n r
wn ra Name. hone:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUTLDINGELECTRICALPLUMBINGMECHANICAL
l c
Lie Ns
Z `
Itect/Englnar. Lk. No:
O 6
CATEGORY
CONTROL N
QTY ELECTRICPERMIT FEE -
BUILDING PERMIT INFO
❑ ❑ ElCENSED
PERMBTISSUANCE
CONTRACTOR'S DECLARATION
Iherebyaffum that l amlleenaed under provisions of Chapter9(mmmenc
Inense1,ed1.n7me afd citedn3o(theButlnmand ProfeasionsCade, and my
license is In (uRtarce and cited. q
License CI`am = Lie N_
Date Com-czz` _UP
ARCHITECTS DECLARATION
I understand my plane shall be used as public records.
Licensed Pmfmimul
OWNER -BUILDER DECLARATION
I hereby affirrnthat I am exempt fromthe Contractor. License Law for the
following remon.(Section 7031S, Businm and Professions Code: Any city or
crentywhich requires a permit to construct, alter, Improve, demolish, orrepair
anystmMmptlortoihi ance,alsonquireetheappliantforsuchpermitto
file a signed statement that he ta licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9 (comeramcing with Section 7000) of Divi-
slon3 of the Business and Prefmakma Cade) orthat beta camps therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
xpplicenl lots permit subjecuitheapplicantto a civil penalty of not more than
five hundred1, asoowndoler of the pro
❑ I, as owner It the property, or he employes with wages r their sole
compensation, B..ia the work and ionsC durc h not Intended or mmoffered for
d.inoe (Sec. p 44, Busmen and Professions Code: The Contmdors hereon law
don not apply torn imserdthroug hiswho
who does such nembuilds arimproovided that such
misarework tleden edorough his own le. If, employees, thebuihaisuch
improvementsarenotintended earo(redlonion. ILhowoveq tilderwdinga
improvement tawid within oneyear.f<.mpldlon, theowner-W IlderwBlhave
tkq.IIurden of proving that he did not build or improve for purpose of sale.).
I, as owner of the property, am mdusively con....u, with lireneed
contractors to construct the project (Sec 7014, Businessand Promakmi, Code:
The Contractors License law does not apply /o an owner of properly who
Wilde or Improves thereon, and who contracts for such plojecta with a
co}JLLtjjador(s) licensed pursuant to the Contractor', License Law.
LJ I am exempt under Sec. B & P C for this reason
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
��'j —
PANELS
TO 2DO AMPS
201-IODDAMPS
OVERIOMAMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL,
SPECIALCIRCUIT/
TEMP. METER OR POLE
POWER DEVI S
SWAfMING L
OUTLETSSWI
VALUATION
�s
V
NRW RESID L EL �'�'
Sao) ES
TYPE CONSTRUCTION
TOTAL:
QTY, PLUMBING PERMIT FEE
CCC.GROUP
RFS. UNITS
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EA)
ELOODZONE
APN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y_ N
BBC=N
Owner Dere
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that 1 have o InHOatn of consent xt opythenco ora
certificate ofWorkeri Compensation lruunna ora rertifkd copytherco!(Sac.
3N ab C. o
1'0l a !
CF-34
Com env— _hereby
SCHOOL TAX Y N
RECEIPT It
GAS EA. SYSTE,14 INCA
PARK FEE Y_ N_
RECEI'IN
GAS EA.SYSIFM-OVER6(EA)
BUILDING DIVISION F[GS
copy is filed
Certified copy ta Ned with the city inspection division.
the city
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE
Uhtasectlan need rad W permit If the pedt h !.cone hundred dollars
(5100)orlmJ
I U nm employthat in any pemmhe in ance o/lhe weer w u to bome permit .tai. issued, d.
I .rk not employ any person In any manner so n to become abject to the
Workers' Compeneatlon Tawe o/ California. Date
Applicant
shoulNOTICE esubjettotheafter makingthissation provisionsfthe ,you
Labor
Code, ou=a.forted/o the Workers' Compensation provisions
Code, d re Rwenforthwith comply with each provtaloro or this perms shall be
deemed revoketl.
CONSTRUCTION LENDING AGENCY
IherebyafOrm thatthem haconatrudlon lendingagenry, forthe perform
ani of the work for which this permit h imaed (Sec 3097, Civ. CJ
Lander. Name
Lender'. Address
I certify that) have read thisappgcetionand elate thattheabove Information
hcarred. l agree to comply with all city and county ordinances, and nate law.
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentloned property fee inspection purposes.
(We) agree to save, indemnify an d keep harmlm the City o/ Cupertino
a Wt liabilities, lu dgntenta,mats arad expenses which may In any way same
ga tmid Clyc9n .a.rfthe granting.f this permit
�sl a -/Y_7'9
CREASE/INDUSTRL WASE INTERCEPTOR
PLANCHECK FEE
PAID
Date RCCCI [#
GREASE TRAP
SEWER -SANITARY -STORM EA. 200PT.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Remi til
WATERS'YSTTiM/TRUATTNC
NEW RESIDENTIAL PLMB.—SQ1IT.
TOTAL:
BUILDING FEEU
�
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY, MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
ALTER OR ADD TO MUCH.
D ale Receipt#
AIR HANDLING UNIT CFO 10,0DO CFM)
SUBTOTAL:
AIRHANDLING UNIT ROVER I0,00(ICFM)
CONSTRUCTION TAX
51g re of Applicant/Contractor Date
HAZARDOUS MATERI 5 DISCLOSURE
illthe applicant orfutumm building occupant atom or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
I Im Ith and Safety Codk§l:dion 75532(x)7
❑ Yea I%�di. No
Willtheappbont or tum building occupant use equipment ordeviure
which emit hazardous air contaminants rs defined by the Bay Area At,
Quality Managementtrid7
Yee o
I have read the hazy .us, materials requirements under Chapter 6.95 of
the California Health& fety Code, Sections 75505,25533 and 75536.1
understand that if the building does not mmently have a tenant, that It is my
responsibility to notify the occupant of the requirem
requirement. which =at be and
prior to issuance d a Certificate of Occupancy.
ExHAWOD
'F I IO(W/DUCT)
CONSTRUCTION TAX PAID:
-
HEATING UNIT (M 10,000 BTLJ)
_
Date Rece1 t#
HEATING UNIT (OVER 100,000 BTU
TOTAL:
r—/1
VENTILATION FAN (SINGLE RESID)
I$$U �1TE
�,ia� 01990
/a, ,.a..4.m Y
City of aallnRo
1
ISSUED BY: y— V�l r,
I'
BOrLER-COMP OHP OR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MF.01. SQFT.
Owne,minithonadagent Date
TOTAL:
OFFICE COPY